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1.
Jui-Yuan Chung Chien-Chin Hsu Jiann-Hwa Chen Wei-Lung Chen Hung-Jung Lin How-Ran Guo Chien-Cheng Huang 《The American journal of emergency medicine》2019,37(3):391-394
Background
The shock index is a rapid and simple tool used to predict mortality in patients with acute illnesses including sepsis, multiple trauma, and postpartum hemorrhage. However, its ability to predict mortality in geriatric patients with influenza in the emergency department (ED) remains unclear. This study was conducted to clarify this issue.Methods
We conducted a retrospective case-control study, recruiting geriatric patients (≥ 65?years) with influenza visiting the ED of a medical center between January 01, 2010 and December 31, 2015. Demographic data, vital signs, shock index, past histories, subtypes of influenza, and outcomes were included for the analysis. We investigated the association between shock index ≥1 and 30-day mortality.Results
In total, 409 geriatric ED patients with mean age of 79.5?years and nearly equal sex ratio were recruited. The mean shock index?±?standard deviation was 0.7?±?0.22 and shock index ≥1 was accounted for in 7.1% of the total patients. Logistic regression showed that shock index ≥1 predicted mortality (odds ratio: 6.80; 95% confidence interval: 2.39–19.39). The area under the receiver operating characteristic was 0.62 and the result of the Hosmer–Lemeshow goodness-of-fit test was 0.23. The sensitivity, specificity, positive predictive value, and negative predictive value of a shock index ≥1 were 30.0%, 94.1%, 20.0%, and 96.4%.Conclusions
A shock index ≥1 has a high specificity, negative predictive value, and good reliability to predict 30-day mortality in geriatric ED patients with influenza. 相似文献2.
Lynn Jiang Nicholas D. Caputo Bernard P. Chang 《The American journal of emergency medicine》2019,37(3):506-509
Objective
Early identification of shock allows for timely resuscitation. Previous studies note the utility of bedside calculations such as the shock index (SI) and quick sepsis-related organ failure assessment (qSOFA) to detect occult shock. Respiratory rate may also be an important marker of occult shock. The goal of our study was to evaluate whether using a modified SI with respiratory rate would improve identification of emergency department sepsis patients admitted to an ICU or stepdown unit.Methods
A prospective, observational cohort study of the respiratory adjusted shock index (RASI), defined as HR/SBP?×?RR/10, was conducted. RASI was calculated from triage vital signs and compared to serum lactate. Primary outcome was admission to a higher level of care defined as ICU or stepdown unit. A multivariable logistic regression model including RASI, SI, lactate, age and sex was performed with disposition as the outcome variable. Areas under the curve (AUC) were calculated to detect occult shock and level of care for RASI, SI, and qSOFA.Results
408 patients were enrolled, 360 were included in the analysis. Regression analysis revealed that lactate (OR 1.55, z?=?4.38, p?<?0.0001) and RASI (OR 2.27, z?=?3.03, p?<?0.002) were predictive of need for higher level of care. The AUC for RASI, SI, and qSOFA to detect occult shock were 0.71, 0.6, and 0.61 respectively. RASI also had a significant AUC in predicting level of care at 0.75 compared to SI (0.64) and qSOFA (0.62).Conclusions
RASI may have utility as a rapid bedside tool for predicting critical illness in sepsis patients. 相似文献3.
Yongzhen Zhao Yumei Jia Chunsheng Li Yingying Fang Rui Shao 《The American journal of emergency medicine》2018,36(1):43-48
Objective
To evaluate the efficacy of soluble programmed death-1 (sPD-1) for risk stratification and prediction of 28-day mortality in patients with sepsis, we compared serum sPD-1 with procalcitonin (PCT), C-reactive protein (CRP), and the Mortality in Emergency Department Sepsis (MEDS) score.Methods
A total of 60 healthy volunteers and 595 emergency department (ED) patients were recruited for this prospective cohort study. According to the severity of their condition on ED arrival, the patients were allocated to the systemic inflammatory response syndrome group (130 cases), sepsis group (276 cases), severe sepsis group (121 cases), and septic shock group (68 cases). In addition, all patients with sepsis were also divided into the survivor group (349 cases) and nonsurvivor group (116 cases) according to the 28-day outcomes.Results
When the severity of sepsis increased, the levels of sPD-1 gradually increased. The levels of sPD-1, PCT, CRP and the MEDS score were also higher in the nonsurvivor group compared to the survivor group. Logistic regression suggested that sPD-1, PCT, and the MEDS score were independent risk factors for 28-day mortality of patients with sepsis. Area under the curve (AUC) of sPD-1, PCT and the MEDS score for 28-day mortality was 0.725, 0.693, and 0.767, respectively, and the AUC was improved when all 3 factors were combined (0.843).Conclusion
Serum sPD-1 is positively correlated with the severity of sepsis, and it is valuable for risk stratification of patients and prediction of 28-day mortality. Combining sPD-1 with PCT and the MEDS score improves the prognostic evaluation. 相似文献4.
Eileen Shu Leyla Farshidpour Megann Young Michael Darracq Crystal Ives Tallman 《The American journal of emergency medicine》2019,37(3):502-505
Background
Synovial lactate is a promising biomarker to distinguish septic from aseptic arthritis. If available as a point-of care test, synovial lactate would be rapidly available to aid the emergency provider in clinical decision making. This study assesses the test characteristics of synovial lactate obtained using an EPOC© point-of-care (POC) analyzer to rapidly distinguish septic from aseptic arthritis in the emergency department.Methods
We enrolled a convenience sample of patients with possible septic arthritis presenting to the emergency department at a large urban academic center between October 2016 and April 2018. Enrolled patients underwent arthrocentesis based on the clinical judgment of the treating provider. We obtained synovial lactate levels (SLL) from the POC device. Standard laboratory analysis, synovial fluid culture, emergency and hospital course, operative procedures, antibiotics, and discharge diagnosis were abstracted from the electronic medical record.Results
Thirty-nine patients undergoing forty separate arthrocentesis procedures were enrolled in this study over the two-year period. The sensitivity and specificity of SLL?≥?5?mmol/L was 0.55 and 0.76 respectively, with +LR 2.3 and ?LR 0.6. The sensitivity and specificity of SLL?≥?10?mmol/L was 0.27 and 0.97 respectively, with +LR 7.9 and ?LR 0.8; SLL?≥?10?mmol/L performed similarly to overall synovial WBC?≥?50,000/μL by conventional laboratory testing.Conclusion
It is feasible to obtain a synovial lactate level using the EPOC© POC device. In our study, POC SLL performs similarly to other markers used to diagnose septic arthritis. Further study with larger sample sizes is warranted. 相似文献5.
Christopher L. Hunter Salvatore Silvestri Amanda Stone Anne Shaughnessy Stacie Miller Alexa Rodriguez Linda Papa 《The American journal of emergency medicine》2019,37(1):114-117
Objective
To determine if prehospital identification of sepsis will affect time to Centers for Medicare and Medicaid services (CMS) sepsis core measures and improve clinical outcomes.Methods
We conducted a retrospective cohort study among septic patients who were identified as “sepsis alerts” in the emergency department (ED). Metrics including time from ED registration to fluid resuscitation, blood cultures, serum lactate draws, and antibiotics administration were compared between those who had pre-arrival notification by EMS versus those that did not. Additionally, outcomes such as mortality and intensive care unit (ICU) admission were recorded.Results
Of the 272 total patients, 162 had pre-arrival notification (prehospital sepsis alerts) and 110 did not. The prehospital sepsis alert group had significantly lower times to intravenous fluid administration (6?min 95%CI 4–9?min vs 41?min 95%CI 24–58?min, p?<?0.001), blood cultures drawn (12?min 95%CI 10–14?min vs 34?min 95%CI 20–48?min, p?=?0.003), lactate levels drawn (12?min 95%CI 10–15?min vs 34?min 95%CI 20–49?min, p?=?0.003), and administration of antibiotics (33?min 95%CI 26–40?min vs 61?min 95%CI 44–78?min, p?=?0.004). Patients with prehospital sepsis alerts also had a higher admission rate (100% vs 95%, p?=?0.006), and a lower ICU admission rate (33% vs 52%, p?=?0.003). There was no difference in mortality (11% vs 14%, p?=?0.565) between groups.Conclusions
Prehospital sepsis alert notification may decrease time to specific metrics shown to improve outcomes in sepsis. 相似文献6.
The utility of presepsin in diagnosis and risk stratification for the emergency patients with sepsis
Bin Lu Yan Zhang Chen Li Chenyan Liu Ying Yao Minghuan Su Songtao Shou 《The American journal of emergency medicine》2018,36(8):1341-1345
Objectives
To evaluate the value of presepsin in diagnosis and risk stratification of septic patients in emergency department, and investigate the utility in differentiation of gram-positive and gram-negative bacterial infection.Methods
We enrolled 72 patients with sepsis and 23 nonbacterial patients with systemic inflammatory response syndrome (SIRS) who were admitted to the emergency department of Tianjin Medical University General Hospital. Meanwhile, 20 healthy volunteers were included. Plasma presepsin, serum PCT, C-reactive protein (CRP), lactate and white blood cells (WBC) were measured, and APACHE II score were calculated upon admission. The receiver-operating-characteristic curve (ROC) was computed and the area under the ROC curve was for evaluating the value to diagnose sepsis. Then the patients were grouped according to the result of culture and severity of sepsis.Results
The levels of presepsin, PCT, CRP and WBC were apparently higher in sepsis patients than in nonbacterial SIRS group (P < 0.05). The levels of presepsin and the APACHEII score were demonstrated the significant difference among sepsis, severe sepsis and septic shock patients (P < 0.05). The area under the ROC curve of presepsin, PCT, CRP and WBC were 0.954, 0.874, 0.859 and 0.723 respectively. The cutoff of presepsin for discrimination of sepsis and nonbacterial infectious SIRS was determined to be 407 pg/ml, of which the clinical sensitivity and specificity were 98.6% and 82.6%, respectively. Moreover, presepsin was significantly different between gram-positive and gram-negative bacterial infection (P < 0.05).Conclusion
Presepsin was a promising biomarker for initially diagnosis and risk stratification of sepsis, and a potential marker to distinguish gram-positive and gram-negative bacterial infection. 相似文献7.
Alexander R. Levine Midori Tran Jonathan Shepherd Edgar Naut 《The American journal of emergency medicine》2018,36(11):1993-1997
Background
Urinary tract infections (UTIs) are one of the most common reasons women seek treatment in the emergency department (ED). The biomarker procalcitonin (PCT) has gained popularity over the last decade to improve the diagnosis of bacterial infections and reduce unnecessary exposure to antibiotics. PCT has been extensively studied in patients with pneumonia and sepsis and may have additional role in UTI.Methods
A retrospective study of patients who presented to the ED in which a urinalysis test and a PCT level was obtained within the first 24 h of presentation. Signs and symptoms of UTI and urine cultures were reviewed to determine a positive diagnosis of UTI. The area under the receiver operating curve was used to calculate the test characteristics of PCT. Different breakpoints were analyzed to determine which PCT level corresponded to the highest sensitivity and specificity.Results
293 patients were included in this single center, retrospective study. The AUC of PCT to predict UTI was 0.717; 95% CI: 0.643–0.791 (p < 0.001). A PCT threshold of 0.25 ng/ml corresponded to the best combination of sensitivity (67%) and specificity (63%), with a positive predictive value and negative predictive value of 26% and 91%, respectively.Conclusions
A PCT threshold <0.25 ng/ml was a strong predictor of the absence of UTI. The high negative predictive value of PCT may be useful as an adjunct to urinalysis results to rule out UTI and facilitate noninitiation or earlier discontinuation of empiric antibiotics. 相似文献8.
Bo Liu Yun-Xia Chen Qin Yin Yun-Zhou Zhao Chun-Sheng Li 《Critical care (London, England)》2013,17(5):R244
Introduction
Presepsin levels are known to be increased in sepsis. The aim of this study was to evaluate the early diagnostic and prognostic value of Presepsin compared with procalcitonin (PCT), Mortality in Emergency Department Sepsis (MEDS) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score in septic patients in an emergency department (ED) and to investigate Presepsin as a new biomarker of sepsis.Methods
This study enrolled 859 consecutive patients with at least two diagnostic criteria for systemic inflammatory response syndrome (SIRS) who were admitted to Beijing Chao-yang Hospital ED from December 2011 to October 2012, and 100 age-matched healthy controls. Patients were stratified into four groups: SIRS, sepsis, severe sepsis, and septic shock. Plasma Presepsin and serum PCT were measured, and MEDS score and APACHE II score were calculated at enrollment. Comparisons were analyzed using the Kruskal-Wallis and Mann–Whitney U tests.Results
On admission, the median levels of plasma Presepsin increased with sepsis severity. The areas under the receiver operating characteristic (AUC) curves of Presepsin were greater than those of PCT in diagnosing sepsis, and predicting severe sepsis and septic shock. The AUC of Presepsin for predicting 28-day mortality in septic patients was slightly lower than that of PCT, MEDS score and APACHE II score. The AUC of a combination of Presepsin and MEDS score or APACHE II score was significantly higher than that of MEDS score or APACHE II score alone in predicting severe sepsis, and was markedly higher than that of Presepsin alone in predicting septic shock and 28-day mortality in septic patients, respectively. Plasma Presepsin levels in septic patients were significantly higher in non-survivors than in survivors at 28 days’ follow-up. Presepsin, MEDS score and APACHE II score were found to be independent predictors of severe sepsis, septic shock and 28-day mortality in septic patients. The levels of plasma Presepsin were positively correlated with PCT, MEDS score and APACHE II score in every septic group.Conclusion
Presepsin is a valuable biomarker for early diagnosis of sepsis, risk stratification, and evaluation of prognosis in septic patients in the ED. 相似文献9.
Shinya Iwase Taka-aki Nakada Noriyuki Hattori Waka Takahashi Nozomi Takahashi Tuerxun Aizimu Masahiro Yoshida Toshio Morizane Shigeto Oda 《The American journal of emergency medicine》2019,37(2):260-265
Background
The ability of blood levels of interleukin (IL)-6 to differentiate between infection and non-infection in critically ill patients with suspected infection is unclear. We assessed the diagnostic accuracy of serum IL-6 levels for the diagnosis of infection in critically ill patients.Methods
We systematically searched the PubMed, MEDLINE, Cochrane Resister of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, and Igaku Chuo Zasshi databases for studies published from 1986 to August 2016 that evaluated the accuracy of IL-6 levels for the diagnosis of infection. We constructed 2?×?2 tables and calculated summary estimates of sensitivity and specificity using a bivariate random-effects model.Results
The literature search identified 775 articles, six of which with a total of 527 patients were included according to the predefined criteria. The pooled sensitivity, specificity, and diagnostic odds ratio were 0.73 (95% confidence interval [CI], 0.61–0.82), 0.76 (95% CI, 0.61–0.87), and 2.31 (95% CI, 1.20–3.48), respectively. The area under the curve (AUC) of the summary receiver operator characteristic (SROC) curve was 0.81 (95% CI, 0.78–0.85). In the secondary analysis of two studies with a total of 263 adult critically ill patients with organ dysfunction, the pooled sensitivity, specificity, and diagnostic odds ratio were 0.81 (95% CI, 0.75–0.86), 0.77 (95% CI, 0.67–0.84), and 2.87 (95% CI 2.15–3.60), respectively.Conclusions
Blood levels of IL-6 have a moderate diagnostic value and a potential clinical utility to differentiate infection in critically ill patients with suspected infection. 相似文献10.
Romain Jouffroy Anastasia Saade Alexandre Muret Pascal Philippe Maud Michaloux Pierre Carli Benoit Vivien 《The American journal of emergency medicine》2018,36(10):1754-1758
Background
Septic shock is associated with hypovolemia resulting in organs failure and poor prognosis. The first step in hemodynamic resuscitation relies on early fluid expansion. In this study, we describe qualitative and quantitative fluid resuscitation of septic shock initially managed in a pre-hospital setting by a mobile intensive care unit.Methods
Patients with septic shock who received pre-hospital medical care were retrospectively analysed. Qualitative and quantitative fluid resuscitation performed in the pre-hospital setting were analysed. Applying the "grey zone" concept, we define 3 categories of fluid expansion indexed on ideal body weight (IBW): >20ml/kg, 10-20ml/kg and ?<?10ml/kg. The relationship between the pre-specified categories and mortality at day 28 were analyzed.Results
Ninety-five patients were included. The origin of sepsis was mainly pulmonary (68%). Mortality reached 34%. Pre-hospital fluid expansion was performed using serum saline (98%) with a mean of 1158±559ml. An inversed linear relationship between pre-specified categories and mortality was observed. Using logistic regression model, significant association with mortality remained for fluid expansion indexed on IBW: p=0.02, ORa [CI95] = 0.93 [0.89-0.98]. For fluid expansion indexed on IBW?<?10ml/kg, the OR [CI95] was 4.03 [1.78-9.41] (p=0.005) whereas for fluid expansion indexed on IBW?>?20ml/kg, the OR [CI95] was 0.30 [0.13-0.66] (p=0.01).Discussion
Pre-hospital fluid resuscitation in septic shock is mainly performed using crystalloids with quantitative fluid expansion lower than recommended. Low pre-hospital fluid expansion was associated with increased mortality. Further prospective studies are needed to evaluate the impact of optimized early fluid expansion on mortality in the prehospital management of septic shock. 相似文献11.
David C. Mackenzie Aftab M. Azad Vicki E. Noble Andrew S. Liteplo 《The American journal of emergency medicine》2019,37(1):123-126
Objective
We sought to determine test performance characteristics of emergency physician ultrasound for the identification of gastric contents.Methods
Subjects were randomized to fast for at least 10?h or to consume food and water. A sonologist blinded to the patient's status performed an ultrasound of the stomach 10?min after randomization and oral intake, if applicable. The sonologist recorded their interpretation of the study using three sonographic windows. Subsequently 2 emergency physicians reviewed images of each study and provided an interpretation of the examination. Test performance characteristics and inter-rater agreement were calculated.Results
45 gastric ultrasounds were performed. The sonologist had excellent sensitivity (92%; 95% CI 73%–99%) and specificity (85%; 95% CI 62%–92%). Expert review demonstrated excellent sensitivity but lower specificity. Inter-rater agreement was very good (κ?=?0.64, 95%CI 0.5–0.78).Conclusion
Emergency physician sonologists were sensitive but less specific at detecting stomach contents using gastric ultrasound. 相似文献12.
Romain Jouffroy Anastasia Saade Laure Castres Saint Martin Pascal Philippe Pierre Carli Benoit Vivien 《The American journal of emergency medicine》2019,37(1):56-60
Objective
Mechanical ventilation can help improve the prognosis of septic shock. While adequate delivery of oxygen to the tissue is crucial, hyperoxemia may be deleterious. Invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO2) at the intensive care unit (ICU) admission is associated with mortality in patients with septic shock subjected to pre-hospital mechanical ventilation.Methods
We performed a monocentric retrospective observational study on 77 patients. PaO2 was measured at ICU admission. The primary outcome was mortality at day 28 (D28).Results
Forty-nine (64%) patients were included. The mean PaO2 at ICU admission was 153?±?77 and 202?±?82?mm?Hg for alive and deceased patients respectively. Mortality concerned 18% of patients for PaO2?<?100, 25% for 100?<?PaO2?<?150 and 57% for a PaO2?>?150?mm?Hg. PaO2 was significantly associated with mortality at D28 (p?=?0.04). Using propensity score analysis including SOFA score, pre-hospital duration, lactate, and prehospital fluid volume expansion, association with mortality at D28 only remained for PaO2?>?150?mm?Hg (p?=?0.02, OR [CI95]?=?1.59 [1.20–2.10]).Conclusions
In this study, we report a significant association between hyperoxemia at ICU admission and mortality in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. The early adjustment of the PaO2 should be considered for these patients to avoid the toxic effects of hyperoxemia. However, blood gas analysis is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of pre-hospital invasive ventilation. 相似文献13.
Shuzhen Wei Ting Wu Ying Wu Ding Ming Xiaoli Zhu 《Diagnostic microbiology and infectious disease》2019,93(4):339-345
Background
Candida albicans germ tube antibody (CAGTA) may be helpful as a marker for the diagnosis of invasive candidiasis (IC). However, the performance has been variable. We conducted a meta-analysis to assess the diagnostic accuracy of this assay for diagnosing IC.Method
We searched MEDLINE, EMBASE, Cochrane Collaboration databases, reference lists of retrieved studies, and review articles. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and a summary receiver-operating characteristic curve of CAGTA for diagnosing IC were pooled using meta-analysis.Results
A total of 976 patients (262 with proven or probable IC), included in 7 studies, were analyzed. The pooled sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratios and area under the curve were 66% (95% confidence interval [95% CI], 59% to 73%), 76% (95% CI, 58% to 88%), 2.8 (95% CI, 1.5 to 5.8), 0.44 (95% CI, 0.34 to 0.57), 6 (95% CI, 3 to 5), and 0.68 (95% CI, 0.64 to 0.72), respectively. Heterogeneity of specificity was significant.Conclusion
The diagnostic accuracy of the CAGTA assay is moderate for IC. Since the CAGTA assay is not absolutely sensitive and specific for IC, the CAGTA results should be interpreted in parallel with other biomarkers and clinical findings. 相似文献14.
Background
Acute kidney injury (AKI) is a common complication in septic patients, imposing a heavy burden of illness in terms of morbidity and mortality. Serum lactate is a widely used marker predicting the severity of sepsis. A paucity of research has investigated septic AKI in emergency departments (EDs) and its correlation with initial serum lactate level. This study aimed at identifying risk factors for septic AKI and clarifying the link between initial serum lactate level and septic AKI in ED patients.Methods
A retrospective cohort study was conducted at a single tertiary referral medical center. The medical records of all adult ED patients with measurement of serum lactate and creatinine between January 2012 and December 2016 were reviewed. A total of 696 septic patients were stratified into AKI and non-AKI groups according to Acute Kidney Injury Network (AKIN) criteria for further statistical analysis.Results
Ninety-nine septic patients (14.2%) had AKI, with AKIN-I, AKIN-II, and AKIN-III in 71.7%, 11.1%, and 17.2% of patients, respectively. Compared with the non-AKI group, the AKI group had a significantly higher mortality rate (71.7% vs. 21.3%, p?<?0.001). Independent risk factors for septic AKI included liver disease (adjusted odds ratio [AOR]?=?2.02, 95% confidence interval [CI]?=?1.16–3.52), diabetes mellitus (AOR?=?1.73, 95% CI?=?1.11–2.69), chronic kidney disease (AOR?=?1.68, 95% CI?=?1.06–2.66), and initial serum lactate (AOR?=?1.08, 95% CI?=?1.02–1.14).Conclusions
Patients with septic AKI had an overwhelmingly higher mortality rate. The comorbidities of liver disease, diabetes mellitus, and chronic kidney disease were correlated with septic AKI and in combination with an elevated initial serum lactate level had predictive regarding AKI and further mortality in ED septic patients. 相似文献15.
Evaluating vancomycin and piperacillin-tazobactam in ED patients with severe sepsis and septic shock
Christina Le Frank Chu Ronald Dunlay Julian Villar Peter Fedullo Gabriel Wardi 《The American journal of emergency medicine》2018,36(8):1380-1385
Study objective
To determine the frequency and cause of inadequate initial antibiotic therapy with vancomycin and piperacillin-tazobactam in patients with severe sepsis and septic shock in the emergency department (ED), characterize its impact on patient outcomes, and identify patients who would benefit from an alternative initial empiric regimen.Methods
Retrospective cohort study conducted between 2012 and 2015 in which 342 patients with culture-positive severe sepsis or septic shock who received initial vancomycin and piperacillin-tazobactam were reviewed to determine appropriateness of antimicrobial therapy, risk factors for inappropriate use, and outcome data. Univariate and multivariate regression analyses were determined to identify associations between inappropriate antibiotic use and outcomes and to identify risk factors that may predict which patients would benefit from an alternative initial regimen.Results
Vancomycin and piperacillin-tazobactam were inappropriate for 24% of patients with severe sepsis or septic shock, largely due to non-susceptible infections, particularly ESBL organisms and Clostridium difficile. Risk factors included multiple sources of infection (OR 4.383), admission from a skilled nursing facility (OR 3.763), a history of chronic obstructive pulmonary disease (COPD) (OR 3.175), intra-abdominal infection (OR 2.890), and immunosuppression (OR 1.930). We did not find a mortality impact.Conclusion
Vancomycin and piperacillin-tazobactam were an inappropriate antibiotic combination for approximately 24% of patients with either severe sepsis or septic shock in the ED. Patients with known COPD, residence at a skilled nursing facility, a history concerning for Clostridium difficile, and immunosuppression would benefit from an alternative regimen. Future prospective studies are needed to validate these findings. 相似文献16.
Serdar Biricik Hüseyin Narcı Güllü Akbaydoğan Dündar Cüneyt Ayrık Mehmet Özgür Türkmenoğlu 《The American journal of emergency medicine》2019,37(3):411-414
Background
Mean platelet volume (MPV) is an inflammatory marker. Recent studies have shown that there is a negative correlation between platelet count (PC) and MPV and that the ratio of these two values may be more meaningful. The aim of our study was to investigate the diagnostic value of MPV and the MPV/PC ratio in acute appendicitis.Methods
Patients who were admitted to the emergency department and underwent appendectomy for acute appendicitis between January 2013 and May 2016 were evaluated retrospectively.The patients were divided into three groups based on their histopathological findings: the control group (negative appendicectomy) and the uncomplicated and complicated appendicitis groups. Leukocyte count, CRP (C-reactive protein) levels, PC, MPV and the MPV/PC ratio were compared among the groups.Results
A total of 424 patients, including 231 men, were included in the study. The average age of all patients was 34.9?±?13.2?years. There was no statistically significant difference between the uncomplicated appendicitis, complicated appendicitis and control groups in terms of MPV, PC and the MPV/PC ratio. Leukocyte count had a strong discriminatory property based on the area under curve (AUC) 0.73, (p?<?0.001). CRP levels, MPV, PC and the MPV/PC ratio had weak discriminatory power with AUC values <0.65. Using receiver operating characteristic (ROC) analysis, the sensitivity and specificity of MPV were 83.79% and 23.21%, respectively, and 66.48% and 48.21%, respectively, for the MPV/PC ratio.Conclusions
In our study, MPV and the MPV/PC ratio were not useful in the diagnosis of acute appendicitis. 相似文献17.
Belén Gutiérrez-Gutiérrez Isabel Morales Salvador Pérez-Galera Patricia Fernández-Riejos Pilar Retamar Marina de Cueto Álvaro Pascual Jesús Rodríguez-Baño 《Diagnostic microbiology and infectious disease》2019,93(1):63-68
Objective
To investigate whether the magnitude of the change in procalcitonin (PCT) and C-reactive protein (CRP) levels between day 1 and day 2 after the blood culture date is associated with early clinical stability (ECS) on day 3 in patients with bacteremia due to Gram-negative bacteria (GNB).Materials/methods
A prospective cohort study carried out in a 950-bed tertiary hospital in Spain between March 2013 and May 2014. Patients with GNB bacteremia were included. Changes in PCT and CRP kinetics from day 1 to day 2 (?%PCT, ?%CRP) were expressed as percentage of decline in blood levels. Logistic regression was used to identify predictors of ECS. Classification and regression tree analysis was performed to identify breakpoints. The discriminatory power of ?%CRP and ?%PCT as predictors of ECS was assessed by the area under the ROC (AUROC).Results
71 patients were included, and 53 (74.56%) reached ECS. Multivariate analyses showed that SOFA score on day 1, ?%PCT, and ?%CRP were associated with ECS after controlling for confounders. ?%PCT?≥?30% (decline) and ?%CRP?≥?10% (decline) predicted ECS only among patients with SOFA≤3 on day 1 (n?=?54; 43 reached ECS). In these patients, the AUROCs for the prediction of ECS were 0.96 (95% CI: 0.90–1) for ?%CRP and 0.96 (95% CI: 0.90–1) for ?%PCT, respectively.Conclusions
In the subgroup of patients with a SOFA score on day 1 ≤3, a ≥30% decline in PCT or a ≥10% decline in CRP between day 1 and day 2 was a very good predictor of ECS (which in turn was associated with a lower 30-day mortality and a greater clinical cure on day 14). Patients who do not achieve this decrease may need more intensive workup. In this subgroup (with a SOFA on day 1 ≤3), CRP may be preferred due to its lower cost. 相似文献18.
Jeff Houck Daniel Kang Tyler Cuddeford Sarah Rahkola 《Archives of physical medicine and rehabilitation》2019,100(1):60-66
Objectives
To determine if the Patient-Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, self-efficacy, and global rating of normal function (GRNF) scales are able to accurately characterize a patient’s acceptable symptom state (PASS).Design
A cross-sectional analysis, using receiver operator curves and chi-square analysis to explore criteria to determine thresholds (80% and 95% sensitivity/specificity) for PASS that are applicable to PROMIS and GRNF scales.Setting
Phone survey after primary care.Participants
Patients (N=94) attending primary care for musculoskeletal problems.Interventions
Not applicable.Main Outcomes Measures
Accuracy and proportion of patients classified as PASS Yes or No.Results
Receiver operator curve analysis showed significant area under the curve (AUC) values for each PROMIS scale (AUC>.72) and the GRNF rating (AUC=.74). Identified PROMIS thresholds suggested PASS was achieved when scores were at or slightly worse than the US population average. A score of ≥7 and ≤4 characterized patients that were PASS Yes and No, respectively, on the GRNF rating. A moderate (80%) specificity/sensitivity criteria yielded 72.3%-73.5% accuracy for a majority of participants (>69.9%).Conclusion
This analysis suggests the PROMIS and GRNF scales are able to characterize PASS status with moderate accuracy (～70%) for a large portion of patients (～70%). New to this study is the association of self-efficacy with PASS status. PROMIS scales at or slightly worse than the US population average characterized PASS status. 相似文献19.
Adam J. Singer Hui Zheng Samuel Francis Gregory J. Fermann Anne Marie Chang Blair A. Parry Nick Giordano Christopher Kabrhel 《The American journal of emergency medicine》2019,37(1):33-37
Objectives
There is growing evidence that venous thromboembolism (VTE) patients with distal clots (distal calf deep vein thrombosis [DVT] and sub-segmental pulmonary embolism [PE]) may not routinely benefit from anticoagulation. We compared the D-dimer levels in VTE patients with distal and proximal clots.Methods
We conducted a multinational, prospective observational study of low-to-intermediate risk adult patients presenting to the emergency department (ED) with suspected VTE. Patients were classified as distal (calf DVT or sub-segmental PE) or proximal (proximal DVT or non-sub-segmental PE) clot groups and compared with univariate and multivariate analyses.Results
Of 1752 patients with suspected DVT, 1561 (89.1%) had no DVT, 78 (4.4%) had a distal calf DVT, and 113 (6.4%) had a proximal DVT. DVT patients with proximal clots had higher D-dimer levels (3760 vs. 1670?mg/dL) than with distal clots. Sensitivity and negative predictive value (NPV) for proximal DVT at an optimal D-dimer cutoff of 5770?mg/dL were 40.7% and 52.1% respectively. Of 1834 patients with suspected PE, 1726 (94.1%) had no PE, 7 (0.4%) had isolated sub-segmental PE, and 101 (5.5%) had non-sub-segmental PE. PE patients with proximal clots had higher D-dimer levels (4170 vs. 2520?mg/dL) than those with distal clots. Sensitivity and NPV for proximal PE at an optimal D-dimer cutoff of 3499?mg/dL were 57.4% and 10.4% respectively.Conclusions
VTE patients with proximal clots had higher D-dimer levels than patients with distal clots. However, D-dimer levels cannot be used alone to discriminate between VTE patients with distal or proximal clots. 相似文献20.
Hernan Polo Friz Valentina Pezzetti Annalisa Orenti Alessandro Caleffi Valeria Corno Chiara Crivellari Francesco Petri Melisa Polo Friz Veronica Punzi Daniela Teruzzi Luca Cavalieri d&#x;Oro Cristina Giannattasio Giuseppe Vighi Claudio Cimminiello Patrizia Boracchi 《The American journal of emergency medicine》2019,37(5):799-804